CLINICAL MEDICINE

Image Diagnosis: Hemorrhagic Bullae

in a Primary Varicella Zoster Virus Infection
Cátia Canelas, MD; João M Carvas, MD; Cristiana Sevivas, MD; Dina Carvalho, MD Perm J 2016 Fall;20(4):15-206
E-pub: 09/01/2016 http://dx.doi.org/10.7812/TPP/15-206

CASE REPORT
A 47-year-old man, 20 pack-per-year
smoker, and heavy alcohol drinker, with
an episode of pulmonary tuberculosis 10
years previously, presented to the Emer-
gency Department with 7 days of cough,
mucous sputum, and abdominal pain.
Additionally, he presented with 5 days of
a pruriginous skin rash that started on the
thorax but rapidly disseminated to the en-
tire body, and with 3 days of fever. Physical
examination revealed dyspnea, polypnea,
fever, dispersed ronchi bilaterally upon
chest auscultation, and dispersed papules,
pustules, and hemorrhagic vesicular le-
sions on the skin and oral mucosa (Figures
1 and 2).
A thoracic computed tomography scan
showed peribronchovascular parenchy-
matous densities with areas of ground-
glass opacity, suggesting an infectious
process with endobronchial dissemination
(Figure 3). Fiberoptic bronchoscopy Figure 1. Image of the patient’s anterior thorax and upper abdomen. Note the diffuse maculopapular and
showed scattered ulcerated and vesicular vesicular lesions with hematic content.
lesions in the airway lining. Blood tests
showed cytolytic hepatitis and rhabdomy-
olysis. Despite treatment with acyclovir, were negative; and no relevant immuno- DISCUSSION
ceftriaxone, and azithromycin, the patient suppression factors could be identified. Chickenpox is usually a benign disease,
deteriorated rapidly and exhibited severe Serologic tests were positive for varicella but in immunocompromised individu-
acute respiratory distress syndrome, with zoster virus (VZV)-specific immunoglobu- als it can lead to clinical complications
a PaO2/FiO2 ratio of 95 mmHg. At lin G and immunoglobulin M, determined with significant morbidity and mortality.1
this point our patient was transferred to by enzyme-linked immunosorbent assay VZV infection causes primarily chicken-
the intensive care unit to be started on and enzyme-linked fibrinolytic assay. The pox, which is characterized by a typically
mechanical ventilation, hemodialysis for serum was also positive for VZV deoxyri- disseminated skin rash.2 Lung infection
acute kidney injury, norepinephrine car- bonucleic acid, determined by polymerase because of VZV is uncommon, and it
diovascular support for septic shock, and chain reaction. Because our patient had usually occurs two to seven days after the
extracorporeal membrane oxygenation, no known history of chickenpox, and had appearance of skin rash. The initial cuta-
which he continued for 20 days. The sep- never been vaccinated for VZV, we made neous lesions of varicella often involve the
sis workup from admission was sterile for the diagnosis of primary VZV infection. scalp, face, and/or trunk and are pruritic,
bacteria, fungi, and mycobacteria; serology By day 35 after admission, our patient had erythematous macules. The maculopapular
studies for hepatitis B virus, hepatitis C improved sufficiently and was transfered to phase of infection evolves to a vesicular
virus, and human immunodeficiency virus the medical ward. phase, during which fluid-filled vesicles

Cátia Canelas, MD, is a Resident in the Department of Internal Medicine at Centro Hospitalar de Trás-os-Montes e Alto Douro in Vila
Real, Portugal. E-mail: catiacanelas@gmail.com. João M Carvas, MD, is a Resident in the Department of Internal Medicine at Centro
Hospitalar de Trás-os-Montes e Alto Douro in Vila Real, Portugal. E-mail: jmcarvas@gmail.com. Cristiana Sevivas, MD, is a Graduate
Assistant in the Department of Internal Medicine at Centro Hospitalar de Trás-os-Montes e Alto Douro in Vila Real, Portugal. E-mail:
cristiana.sousa@gmail.com. Dina Carvalho, MD, is a Graduate Assistant in the Department of Internal Medicine at Centro Hospitalar de
Trás-os-Montes e Alto Douro in Vila Real, Portugal. E-mail: dinamota@gmail.com.

The Permanente Journal/Perm J 2016 Fall;20(4):15-206 1

CLINICAL MEDICINE
Figure 2. Magnified image of the patient’s upper
abdomen, showing the dispersed skin lesions
in greater detail. Note the small maculopapular
erythematous lesions and large vesicles with
hemorrhagic content.
appear in existing or new erythematous
lesions, leading to the typical “dewdrop on
a rose petal”3 appearance. In the case we
report here, the skin lesions were not the
typical dewdrop on a rose petal appearance
because of the hemorrhagic content of the
vesicles. Hemorrhagic vesicles in chicken-
pox are very unusual and are generally as-
sociated with severe immunodeficiency.4,5
This was a case of VZV pneumonia in a
young adult patient with an unusual skin
rash and acute respiratory distress syn-
drome, which has a high severity even for
this age group. Our patient had no known
The power of making a correct diagnosis is the key to all success in the treatment of skin
disease; without this faculty, the physician can never be a thorough dermatologist, and
therapeutics at once cease to hold their proper position, and become empirical.
— Louis A Duhring, MD, 1845-1913, American physician and professor of dermatology
2 The Permanente Journal/Perm J 2016 Fall;20(4):15-206
Image Diagnosis: Hemorrhagic Bullae in a Primary Varicella Zoster Virus Infection
history of contact with infected persons or
evidence of congenital or acquired immu-
nodeficiency beyond what was caused by
chronic alcohol and tobacco abuse. Some
components of tobacco smoke are known to
suppress important pathways of the innate
respiratory immune system.6 Clinical stud-
ies have also shown that the incidence of
acute respiratory distress syndrome is much
higher in patients with a known history of
alcohol abuse.7 This case highlights the im-
pact these two habits can have as immuno-
suppressant factors.8,9 Primary infection by
VZV in adults and immunocompromised
individuals may have a more severe presen-
tation and serious complications. Prompt
and accurate diagnosis is essential to prevent
life-threatening sequelae. v
Disclosure Statement
The author(s) have no conflicts of interest to
disclose.
Figure 3. Computed tomography scan of the
patient’s thorax showing peribronchovascular
parenchymatous densities with areas of ground-
glass opacity.
Key to Success
How to Cite this Article
Canelas C, Carvas JM, Sevivas C, Carvalho D.
Image diagnosis: Hemorrhagic bullae in primary
varicella zoster virus infection. Perm J 2016
Fall;20(4):15-206. DOI: http://dx.doi.org/10.7812/
TPP/15-206.
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